Provider Demographics
NPI:1457477440
Name:FIDLER, BRENT W (OD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:W
Last Name:FIDLER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1524 W EISENHOWER BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80537-4343
Mailing Address - Country:US
Mailing Address - Phone:970-667-2954
Mailing Address - Fax:866-858-0953
Practice Address - Street 1:1524 W EISENHOWER BLVD STE C
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80537-4343
Practice Address - Country:US
Practice Address - Phone:970-667-2954
Practice Address - Fax:866-858-0953
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1592152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCG7018Medicare PIN
COU48766Medicare UPIN
COCOA100509Medicare PIN